GW1--03938_Well Construction - GW1_20240705

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1. - Contractor ormation:
•
f4:WATER=ZONES y`....
Well Con tor Name FROM TO DESCRIPTION
• t l eks ft tag ft 7,...d ft ftNC Well Contractor Certification Number �_�415:OUTER A G:(fdrfmuls)OIZL1)!-AR:(ttAP pebble) i<x'x'::` q>:Morgan Well&Pump, INC - FROM TO D THICKNESS MATERIAL '
a ft. ( ) ft 61/8 in. sdr-21 PVC
Company Name
, .<16INNERCASING.OR TUBING:(geothermalclosed-loop):.:;:. :: ;: :':,::. ':)•.:•::!:,;"•,.;::::,; •
2.Well Construction Permit#: 4036,D4 FROM - TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. in. t
3.Well Use(check well use): ft' ft '°'
>17 SCREEN: ::.': :%.:•`:..:.:..:'.:: .<":':: '.. n. '::`
Water Supply Well: FROM. TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ElAgricultliral f Municipal/Public ft. ft. in.
J Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft ft. In.
Dlndustrial/Commercial Residential Water Supply(shared) ::.,
�{ Ibi GROUT `..�: :.. .:. :'. ::.:.:::.. .. ... ... ..:...,:,:.:.•,.:,.....
l Irrigation FROM TO MATERIAL 'EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
Monitoring °Recovery ft. ft. •
Injection Well:
ft. ft.
IDAquifer Recharge InGroundwater Remediation
+� 19:SAND/GRAVELPACK(If applicable) .
f Aquifer Storage and Recovery f Salinity Barrier PROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test fStonnwater Drainage ft ft.
Experimental Technology )Subsidence Control ft. ft. •
(Geothermal(Closed Loop) OTracer :20:1511I1StINGLOG(i'itselraadtttoiialsheets ffneeesua' '
°Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
FROM TO DESCRIPTION(color,hardness,aol frock type,grain she,etc)
d ft aw.k
4.Date We Completed:�� 12'� Well ID# �,�tt ( 5 ft. yy � 1 t
/
5a.Well Location: (0S ft. ` ft 1YW* 4 ! -',"
0 90 ft ' tiF
Facility weer Name Facility ID#(if applicable)
rt n
•
1l1 Pam- ��gG ft. ft. k.. U ;
ft ft.
sical Address,City,and Zip / Ll— Pc JUL �L
Q1 O '�+R�RI�S"�;:.:..:....:....:: :� .���.`t-< �'•:�:"/�[ �'�':;�;iT� :4.
County Parcel Identification No.(PIN) info f 7f'.At t.l : ',:.r :Ant,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. cation• - _-
<SO
35 '7a- N 357/ W / (C/ 4j6.Is(are)the well(s)JPermanent or TemporarySi•.:iT o riffledWell Date
By signing 'form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: •Yes or i...;No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
filled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ` v (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
•For multiple wells list all depths if different(example-3(§200'and 2(g100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2'/699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
• FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) f 5 Method of test: air 24c.For Water Supply&Injection Wells: In addition to sending the form to
I'� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: granulated chlorine Amount: Pies completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016